AP in Detoxification / Withdrawal
FROM DRUGS & ALCOHOL (2/3)
Smith_MO4 (1989) AP Treatment for Drug Addiction. Consequently, these women have needs that are quite different than the needs of an unemployed person.
Female drug users are often trapped in very destructive and exploitative relationships. Many drug-related relationships involve violence and abandonment. When we ask a mother with small children to stop using drugs, we are usually asking her to leave her home and her relationship as well as the identified addiction. These women are often forced to live in a shelter or welfare hotel if they leave the apartment where their crack-using companion remains in physical control. In a previous session of this subcommittee, we heard that shelters and welfare hotels are hardly safe harbours in the drug abuse war. A woman with small children is uniquely vulnerable to the intimidating and intrusive nature of the crack sub-culture.
Immediate pressures of child care may also hinder a woman's response to treatment. We instruct AP patients to sit quietly in the chair while the needles are in place. This request takes on an entirely different meaning when the maternal patient has a newborn and a 2-yr-old with her. Attendance in Narcotics Anonymous is also more difficult when children tag along. Every day in our clinic 45-50 women bring small children with them during treatment. We appreciate their commitment to parenthood, but also recognize the increased challenge of their regular attendance. Many of our new mothers visit the hospital each day to feed their infant. Others have to make difficult arrangements for child care.
All too often women are said to have greater resistance to treatment than men. Reality-based fear of physical violence may be falsely interpreted as only part of their fear of confronting addiction. Dependence on living in an apartment and a relationship where crack happens to be used will compound the apparent degree of dependence on the drugs.
At Lincoln we have been able to design a program with a relatively high rate of success for women with small children. AP provides convenient relaxation and reduction of fear on a daily basis. Scheduled appointments are not necessary. Frequent supportive sessions are used rather than early stage confrontations that are often typical of drug-free programs.
Let me conclude this discussion by mentioning one principle that is vital to the success of any maternal substance abuse program. The program must work in terms of the women's autonomy and ask her to become drug-free for herself, not "for the sake of her baby." Guilt is not a good medicine. A person who appreciates her own value will be a better parent and also be able to say "no"to drugs and drug-filled relationships.
Enhancements of the maternal substance abuse program
New York City Council President Stein's office designated $181,000 of fiscal 1989 to establish a unique pre-natal substance abuse program at Lincoln Hospital. The pregnant substance abuser is treated initially for addiction as the primary problem. She receives AP, counselling, urine testing, using the regular protocol. Education about pregnancy and delivery, pelvic examination and more stressful testing will be done when the patient is ready to handle these matters. City Controller Harrison Goldin has designated $110000 in the fiscal 1990 budget to develop a parent education program in conjunction with our postpartum program. The Dept of health will help us track long-term follow-up for these patients as well as our whole postpartum case load.
AIDS prevention
As we have indicated, AP detoxification is a popular and safe method of relieving stress and craving in a wide range of substance abusers. >60% of clients are retained in AP treatment, a much higher figure than any other form of outpatient drug-free treatment. No other drug abuse program except for Lincoln has ever been able to accept poly-drug abusers and mentally ill chemical abusers on an unscreened walk-in basis so that 10 new patients/d can receive acceptable treatment on the day of admission. Lincoln Hospital has a long history of being able to reach the unreachable patient, including some homicidal, paranoid and bizarrely psychotic persons who would be rejected in many sites due to the perception of risk of violence. The following patient summaries indicate that an AP program can reach "unreachable" clients. The patient described is typical of the AIDS-patients who will be most difficult to relate to and therefore will be more likely to spread the condition.
HW presented with a narcotic and cocaine habit and an obviously paranoid condition. He had a history of LSD psychosis in 1972 and at least 3 state psychiatric hospitalizations. HW was evidently hearing voices and reported bizarre somatic delusions. HW attended AP 5-6 d/wk for the next 6 mo. After d 1, he said that his voices "went away." Use of heroin and cocaine continued intermittently. HW was so guarded that no individual verbal sessions were attempted until 6 mo later. HW is now readily communicative, working part-time and attends AP once/wk.
Involving the HIV(+) or PWA person in drug abuse treatment can be the first step in the overall Med treatment of AIDS and a necessary step in the development of sexual responsibility which will protect spouses from the epidemic. The Health Commissioner Steven Joseph has strongly supported this point of view in previous testimony before the New York City Council. The statistic that is most often cited as an indication of the danger of heterosexual spread of AIDS is the rate of HIV(+) findings in mothers and their babies. These statistics have been used to advocate programs such as methadone maintenance and syringe exchange; programs which relate mainly to male narcotic addicts. Helping a man use narcotics "safely"will not necessarily help him use sexual precautions with women he is involved with. The use of cocaine and alcohol tends to increase sexual irresponsibility.
Only a program which directly helps young women become drug-free will have a substantial effect on the rate of HIV(+) findings in mothers and children in the special context of widespread infection in New York City. These women can then involve their partners in treatment. One of our patients told me her husband walked with her to the clinic with a baseball bat in case she did anything wrong. From my office window I could see the man standing on the street with a bat. 2 wk later this patient brought her husband into the clinic for treatment, saying "he doesn't use drugs, he just wants treatment for nerves." Our patient had made a tremendous accomplishment, one that could have been sabotaged easily by premature confrontation.
Medical-scientific reaction
We are often asked about the reaction of the Med scientific community to our use of AP. Because of my own initial scepticism, I understand a natural reluctance to consider the possibility that AP could be effective for such a serious condition as cocaine addiction.
Dr Milton Bullock and acupuncturist Patricia Culliton of Hennepin County Med Centre in Minneapolis began to use a placebo protocol to evaluate our Lincoln Hospital AP protocol in 1983.
Smith_MO5 (1989) AP Treatment for Drug Addiction. Their first article was published in the Alcoholism J in June 1987. It showed that 37% of the treatment group responded well to AP as compared to 7% of the placebo group which received non-specific AP points. The Hennepin group has published a more advanced study in Lancet (June 24, 1989), the prestigious journal of the BMA. 21/40 treatment AP patients completed the program compared to 1/40 controls. Significant treatment effects persisted at the end of a 6-mo follow-up. These studies focus on severe recidivist alcoholics who are very rarely engaged in outpatient management.
Dr Mindy Fullilove of the Univ of CA at San Francisco is just completing a controlled placebo study using the Lincoln protocol with IV heroin abusers. Dr Stephen Kendall and his staff at Beth Israel in New York have planned a controlled study using AP to treat addicted babies. A controlled placebo study by Dr Doug Lipton of the Narcotic Drug Res Inst (NDRI), is under way in crack-patients at Lincoln Hospital. In the recent submission of large scale AIDS prevention drug abuse treatment grants, AP was the second main procedure suggested for evaluation.
In a recent legislative meeting in Albany, New York, the chief representative of the Med Society of New York stated that AP was an important part of the health care field and that physicians were seeking more instructive and more active participation in the AP field.
Relations with the Drug Abuse Treatment Field.
I have always supported the position that AP can only be component part of the whole process of drug abuse treatment. Nearly all of the existing AP drug abuse programs were developed within already existing licensed treatment programs. Our enabling legislation in New York State was written by Public Health Commissioner Deborah Prothrow Stith, the state drug abuse agency of Massachusetts has funded 4 AP-based programs during 1989. Many methadone programs have established AP components in order to treat crack abuse and other secondary addictions. In a therapeutic community setting, such as the Phoenix House in London, staff members report that AP helps reduce craving, tension among the clients and that most clients participate in the weekly AP sessions.
A South Bronx Clinic has gained world-wide recognition
The Lincoln Hospital AP program has received a great deal of national and international attention. >60 clinics in the US and another 25 in Europe, Latin America and Asia have been established explicitly on the model of our clinic in the South Bronx. Indeed Lincoln Hospital has become a "mecca" for visitors and journalists. Television networks from Spain, Italy, Brazil, Sweden, UK, Latin America, Hungary and Japan have filmed our AP drug abuse program.
The National AP Detox Assoc (NADA) was founded in 1985 by clinicians who wanted to extend the example of the Lincoln hospital experience into other treatment settings. I am the chairperson of NADA. The organizational name also uses the Spanish connotation of "nada", suggesting a no-nonsense, drug-free approach. NADA has given many training programs for public institutions and communities in undeveloped areas. It has set standards of certification for AP detoxification specialists that are widely accepted in the substance abuse field.
I have just returned from a UN meeting in Spain scheduled to plan community-based treatment programs on a widely diversified basis. In the December 1988 issue of the Bulletin of Narcotics, we described NADA programs on the Sioux reservation, in Katmandu, in La Perla in Puerto Rico, and Lincoln as an example of the effectiveness of this model in difficult socioeconomic settings.
It is easy to be confused by the aggressiveness that many addicts present and to conclude that the main goal should be symptom suppression. The addict himself takes this approach in the extreme by using sedative narcotics. In contrast, we have derived our approach from TCM theory of detoxification. In TCM the lack of calm inner strength is described as Empty-Fire (Xu-huo), because the Heat of aggressiveness burns out of control when the calm inner tone is lost. The hostile paranoid climate of communities vulnerable to drugs is a clear example of Qi-Xu Syndrome with Empty-Fire burning out of control.
Our patients seek greater power and control over their lives. Empty-Fire is the illusion of power, an illusion that leads to more desperate chemical abuse and senseless violence. AP is an effective treatment for Empty-Fire. The patient is empowered, but in a soft, easy and long-lasting manner.
Smith_MO6 (1986) AP Treatment for Alcoholism. Adapted from WWW, NADA Home Page. Michael O Smith MD DAc, Lahary Pittman, CAC, CA, Ana Oliveira, MA, CA.
The Lincoln Hospital Substance Abuse Division, Bronx, NY, has been detoxifying alcoholic clients with AP since 1974. We combine these innovative methods with the conventional modalities of counselling and in-patient detoxification. We see hundreds of detoxification clients daily in an inner city, walk-in clinic. The data reported here for alcoholism treatment are similar to those we have found for drug addiction and other substance use disorders. Specifically, we are doing an extensive urine survey to evaluate our results obtained treating cocaine or "crack" patients on an out-patient basis.
AP detoxification is relatively simple to learn and apply. Small needles are inserted just under the skin at several locations on the external ear. Clients usually begin AP out of curiosity or desperation. They continue to come for treatments as they appreciate the success of the treatment. Clients who come in tremulous often fall asleep during treatment. Clients who come once/d for >7 d find it easier to remain sober and are visibly more relaxed, alert and confident. Some motivated, as well as poorly motivated clients report that daily AP treatment makes it very difficult to keep drinking. Several have told us that they still hang out with their drinking buddies but "don't feel like drinking".
Many people in this field burn themselves out trying to use counselling methods only to cope with chronic tension, craving and insomnia. These symptoms reflect total body imbalance, not only psychosocial imbalance. Nagging physical withdrawal symptoms and debilitating fears of "white-knuckle sobriety"respond quite well to AP and herbology combined with counselling methods. Our treatment methods help the counsellor's efforts to be much more fruitful.
Since AP is inexpensive and non-addicting, we can easily offer AP treatments "on demand." An addict in withdrawal need not be placed on a waiting list and be lost to follow-up. The cost of AP detoxification is much less than alternate protocols. AP treatment can be provided within a general Med setting so that treatment of significant others and concurrent psychiatric and abuse problems can occur simultaneously. Repeat in-patient detoxification is inappropriate for relapsing clients who have not yet built up a substantial habit. By offering treatment "on demand"the AP detoxification protocol minimizes the barriers for the former client to re-enter treatment. Discussions of stressful psychosocial issues can be delayed until after the client has received renewed relief and reassurance by the effectiveness of AP treatment.
Alcoholism clients particularly appreciate a concerned, giving atmosphere. AP allows the staff to help give relief without any physical symptoms because it helps modify the point selection. We have had additional success in treating nerve and liver disease which are secondary to alcoholism. Physical complaints which are a source of nagging irritation in the usual treatment setting thus become a useful communication in the AP detoxification setting.
In our specialty, a disproportionate amount of time and money are spent on in-patient detoxification. Using AP as an adjunct to our patient's alcoholism treatment enables us to serve a much larger group of clients and allows us to invest more time in the interpersonal and spiritual aspects of rehabilitation. Clinical sites using AP find many less problems related to the management of violence and other disruptive behaviours.
Research studies at Lincoln
We were able to apply the breathalyser testing to our alcohol-related clients before almost every AP visit in June, 1985. This extensive testing provides a unique opportunity to evaluate the detoxification and early sobriety status of AP treatment. These clients completed a treatment agreement as part of the one page intake form. They often received social service support and referral from the intake counsellor. However, no long term treatment slots were available so none of the intakes and relatively few of the longer term clients have any access to regular counselling. Only a handful of these clients attend AA. Psychotic clients and clients with secondary substance abuse habits are not screened out and are included in the sample.
50 intakes in June were found to have a primary problem of alcoholism. Most clients are diagnosed by other agencies and give a 10-20 yr drinking history. Clients with >1 breathalyser tests/wk and a total of 8 tests are included in the sample as active clients. 7 intakes entered so late in the month as to have insufficient tests for inclusion. 18/43 remaining (42%) had no positive breathalyser test. This usually means that even on the second day of treatment, they are breathalyser clean. 12/43 (28%) were classified as "oscillating" because they have occasional positive tests but had on the mean 3 times as many negatives as positives. 12 were categorized as "drop-outs, "usually with 13 visits reported. One person continued active drinking. Therefore, 70% of these diagnosed alcoholics show regular attendance and predominant breathalyser sobriety in an AP setting without regular counselling follow-up.
The data for the entire alcohol-related population, June intakes included, are similar for the same period. A total of 215 clients received at least 2 breathalyser tests/wk before AP treatment. We should mention that the clients line up very cooperatively for testing and voice disappointment if testing is not available at a given time.
99/215 subjects (46%) showed no positive test during the month. 17/215 (8%) were classified as "improved"because they gave all negatives after an initial series of positives. 98/215 (46%) were classified as "oscillating, "again with a mean of 3 times as many negative tests as positive ones. One client had consistently positive tests.
A positive breathalyser test was used as a tool of intervention. Clients were required to speak to their intake counsellor or their long term counsellor if an assignment had been made. People who were grossly intoxicated were asked to leave without treatment and return on the next day. Clients with low positives had brief sessions on the importance of daily sobriety. No one was asked to leave the program on a long term basis because of positive tests. A handful of people were referred for hospital detox. No more than 20-30 of these 215 clients were attending a long term alcoholism program.
The data for June indicate that our AP program can function well as an early sobriety phase of alcoholism rehabilitation. Circa 50% of the clients remain sober for several mo with frequent AP treatment, breathalyser monitoring and minimal counselling. These clients are certainly ready for referral to AA and long term outpatient rehabilitation.
The "oscillating" group of clients can maintain frequent sobriety and continuing relationship with a treatment process. These clients would certainly benefit from alcoholism awareness classes and one-to-one counselling that a more properly staffed program would provide.